Provider Demographics
NPI:1033182431
Name:REDDY, NALLU R (MD)
Entity Type:Individual
Prefix:
First Name:NALLU
Middle Name:R
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 BOLTON BOONE DR
Mailing Address - Street 2:STE 111
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2019
Mailing Address - Country:US
Mailing Address - Phone:972-780-0357
Mailing Address - Fax:972-780-7829
Practice Address - Street 1:2727 BOLTON BOONE DR
Practice Address - Street 2:STE 111
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115
Practice Address - Country:US
Practice Address - Phone:972-780-0357
Practice Address - Fax:972-780-7829
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8637207R00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00PR65Medicare ID - Type Unspecified
00PR65Medicare PIN
C20928Medicare UPIN